Letters
Figure 1 Analogy to the
individualistic country like the UK.6 Thus, the iceberg concept
and Hofstede’s theory can both be used as tools to aid
understanding of the existing distinct cultural characteristics
and their implications.
These differences seem to be too vast to be tackled, but
they are too important to ignore. We believe that a long-term,
systematic ‘cultural integration’ can complement standard
hospital induction programmes. The first step in bridging
the cultural gap is to increase awareness among overseas
doctors that such differences and challenges are inevitable, and
that this information should be accessible on a single online
resource hub. Equally, NHS staff should be educated about the
rich cultural diversity of the NHS to create a working practice
that recognises and respects cultural differences. Finally, on
a par with most academic institutions, NHS trusts can adopt
a ‘buddy scheme’ or ‘cultural ambassador’ for newly arrived
overseas doctors, in order to help them settle within the local
community. We believe these measures would allow overseas
doctors to be better prepared within the NHS, permitting them to
have not only greater cultural integration, but also an improved
work environment, thus providing better care for patients.
Anna Zonato1, Mustafa Jalal2,3
1
Accident and Emergency Department, Norfolk and Norwich
University Hospitals, Norwich, UK
2
Department of Infection, Immunology and Cardiovascular
Diseases, University of Sheffield, Sheffield, UK
3
Academic Department of Gastroenterology, Sheffield
Teaching Hospitals, Sheffield, UK
Email: annazonato@gmail.com
doi: 10.4997/JRCPE.2021.231
206 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH VOLUME 51 ISSUE 2 JUNE 2021
concept of cultural complexity
is the cultural iceberg. Some
elements of culture are
observable to a new overseas
doctor, but the majority of
cultural elements are not
observable and hidden
beneath the surface.
References
1 GMC. Welcome to UK practice: information for doctors. https://www.
gmc-uk.org/about/what-we-do-and-why/learning-and-support/
workshops-for-doctors/welcome-to-uk-practice (accessed 26/2/21).
2 GMC. Registered doctors by country of primary medical qualification.
https://data.gmc-uk.org/gmcdata/home/#/repor ts/The%20
Register/World%20maps/report (accessed 26/2/21).
3 Slowther A, Lewando Hundt GA, Purkis J et al. Experiences of non-
UK-qualified doctors working within the UK regulatory framework: a
qualitative study. J R Soc Med. 2012; 105: 157–65. doi:10.1258/
jrsm.2011.110256.
4 Hofstede G. What is culture? https://geerthofstede.com/culture-
geert-hofstede-gert-jan-hofstede/definition-culture (accessed
1/3/21).
5 Hall E. Beyond Culture. New York: Bantam Doubleday Dell Publishing
Group; 1976.
6 Morrow G, Rothwell C, Burford B et al. Cultural dimensions in the
transition of overseas medical graduates to the UK workplace. Med
Teach 2013; 35: e1537–45. doi:10.3109/0142159X.2013.802298.
Snakebites – prevention is better than cure
I would like to thank the JRCPE for the recent editorial by
Bawaskar, Bawaskar and Bawaskar on the global burden of
snakebite envenoming,1 and the related clinical paper on
Hypnale coagulopathy.2 As a public and global health student,
it is encouraging to see a focus on this important yet long-
neglected issue,3 which disproportionately affects poorer,
rural communities.4
I write to draw readers’ attention to the related article in
BBC Future, since published. This is a very readable and well-
researched piece on snakebite with links for further reading
and explores snakebite prevention (such as mosquito nets
to avoid bites from the common krait, a leading cause of
50TH ANNIVERSARY YEAR

snakebite envenoming in India), diagnosis (such as thermal
imaging to identify venom-induced inflammation) and
treatment (antivenom and novel treatments, such as the
potential of DMPS against saw-scaled viper venom).5
In addition to the use of mosquito nets, the BBC Future article
provides another simple way to prevent snakebite: rubber
boots.5 Importantly, the article also highlights the need to
engage with communities, and avoid simply handing out
rubber boots: similar schemes in Africa have failed because
villagers sold off the valuable rubber or found the boots
uncomfortable and stopped using them.5 Indeed, one of
the four strategic aims of the World Health Organization’s
snakebite envenoming prevention and control strategy is
to ‘empower and engage communities’.4 An exemplar of
community engagement and empowerment is SHE-India
(www.she-india.org), which orchestrates low-resource,
community-based actions, including educational posters and
videos in multiple languages, first aid training and partnership
with village leaders and influencers.6 Their awareness-raising
will most likely have prevented countless snakebites from
occurring, saving many lives and limbs, although SHE-India
recognise the need for a sustained, funded study over an
extended period to properly evaluate their work’s impact.6
Meanwhile, physicians have an important role in ensuring
safe and effective treatment to improve outcomes for
snakebite victims and save lives.4 Healthcare professionals
and public health practitioners should work together to further
raise awareness of this neglected, devastating disease, and
to engage and empower those at risk to stop snakebites
occurring in the first place. Prevention is better than cure.
In memoriam
In memoriam brings to the attention of Fellows and Collegiate
Members the deaths of colleagues and friends. Obituaries
paying tribute to the life and work of those whose deaths have
been reported in In memoriam can be found on the College
website: www.rcpe.ac.uk/obituaries
Professor K Yusoff FRCP Edin
Born: 30/01/1955 Died: 05/04/2021
Specialty: Cardiovascular Medicine
MB Melbourne 1980
Dr A Armstrong FRCP Edin
Born: 03/12/1929 Died: 12/04/2021
Specialty: General Internal Medicine
MB Edin 1952, DRCOG 1956, MRCP Edin 1961 Resp
Dr JS Fitzsimmons FRCP Edin
Born: 12/04/1929 Died: 25/04/2021
Specialty: Genetics (Clinical)
MB Belf 1953, DCH Lond 1956, MRCP Edin 1964 Child Life
50TH ANNIVERSARY YEAR JUNE 2021 VOLUME 51 ISSUE 2 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH
IN MEMORIAM
Conflicts of interest
CJG works for Scottish Health Action on Alcohol Problems
(SHAAP), based at the Royal College of Physicians of
Edinburgh (RCPE).
Christopher J Graham1,2
1
Master of Public Health (MPH) Student, Faculty of Biology,
Medicine and Health, University of Manchester, Manchester,
M13 9PL, UK
2
Research & Projects Officer, Scottish Health Action on
Alcohol Problems (SHAAP), Royal College of Physicians of
Edinburgh (RCPE), 12 Queen Street, Edinburgh, EH2 1JQ, UK
Email: c.graham@rcpe.ac.uk
doi: 10.4997/JRCPE.2021.232
References
1 Bawaskar HS, Bawaskar PH, Bawaskar PH. The global burden of
snake bite envenoming. J R Coll Physicians Edinb 2021; 51:7–8. doi:
10.4997/JRCPE.2021.102.
2 Naik BS. Hypnale coagulopathy: snake envenomation of a different
kind. J R Coll Physicians Edinb 2021; 51: 31–36. doi: 10.4997/
JRCPE.2021.108.
3 Snakebite-emerging from the shadows of neglect. The Lancet 2019;
393: 2175. doi: 10.1016/S0140-6736(19)31232-2.
4 World Health Organization. Snakebite envenoming: a strategy for
prevention and control. Geneva: World Health Organization; 2019.
https://www.who.int/snakebites/resources/9789241515641/en.
5 The global fight against snake bites. BBC Future. 2021 April 14.
https://www.bbc.com/future/article/20210413-how-rubber-boots-
can-save-people-from-snake-bites.
6 Kadam P, Ainsworth S, Sirur FM et al. Approaches for implementing
society-led community inter ventions to mitigate snakebite
envenoming burden: the SHE-India experience. PLoS Negl Trop Dis
2021; 15: e0009078. doi: 10.1371/journal.pntd.0009078.
Fellows and Collegiate Members are invited to provide the
Obituaries Editor (editorial@rcpe.ac.uk) with information that
will enable us to write or commission obituaries. Self-written
obituaries to be held in readiness by the Obituaries Editor
will always be welcome.
Dr GM Fraser FRCP Edin
Born: 24/03/1929 Died:
Specialty: Radiology
MB Edin 1951, DMRD Edin 1959, MRCP Edin 1984, CAP
III,12
Dr EJ Johnson MRCP UK
Born: 19/009/1952 Died:
Specialty: Haematology
MB Wales 1976, MBA Leeds 1992
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